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  1. Pich, Jacqueline

Article Content


Pulled elbow is defined as an acute onset condition characterized by pain and sudden loss of function in the affected limb of a child, with the left arm identified as the most frequent site of injury. It is recognized as a common childhood injury in young children up to the age of 7 years.


The mechanism of injury includes the sudden pulling away of a child's arm for various reasons when walking with an adult, by the adult or the child, and as a result of a fall or twist. The sudden pull on the arm causes the head of the radius to be pulled through the annular ligament, the ring-shaped ligament at the elbow. The ligament can partially tear as a result and become entrapped between radial head and capitellum causing subluxation or partial dislocation of the radial head.


Pulled elbow in children is diagnosed using patient history in conjunction with a physical examination. Signs and symptoms include pain, typically felt at the wrist, shoulder, or both, and restricted range of movement in the affected arm. The arm is typically held slightly flexed and twisted inward, with no swelling or bruising evident, and while the elbow can usually be flexed and extended, twisting of the forearm is restricted and results in pain in the elbow.


Treatment typically involves manual intervention to reposition the radial head and the annular ligament and thus to restore function of the arm and relieve pain. There are two maneuvers commonly recommended. The first is supination, where the forearm is twisted or rotated outward, sometimes followed by flexion of the elbow. The second method is pronation, where the forearm is twisted or rotated inward. The side effects of both methods include bruising and pain.



The primary objective of this Cochrane review was to compare the effects (benefits and harms) of the methods used to manipulate pulled elbow in young children. The primary comparison considered was the pronation method versus the supination method.



The review included randomized controlled clinical trials and quasirandomized trials that evaluated manipulative interventions for pulled elbow in children from birth up to adolescence. Trials of various maneuvers in any setting were included.


The primary outcome measure was failure at first attempt. Success was defined as immediate restoration of a pain-free, fully functional arm and failure as the need for subsequent treatment and lack of spontaneous use of the arm by the child.


Secondary outcome measures included:


* Pain and distress during the intervention;


* Bruising and other adverse effects;


* Continued failure after second attempt using the same maneuvers;


* Ultimate failure;


* Recurrence-within 1 month.




There were nine studies included in this review, representing a total of 906 participants aged between 4.5 months and 7 years (Krul et al, 2017). Eight trials were conducted in the emergency department or ambulatory care settings whereas one was performed in a tertiary pediatric orthopaedic setting.


Eight studies compared hyperpronation with supination-flexion for the primary reduction method for treating pulled elbow in young children. For the primary outcome measure, there was low-quality evidence (downgraded for very serious risk of bias) in these studies of a significantly lower risk of failure at first attempt after manipulation with hyperpronation than with supination-flexion.


No difference was identified for pain during or after manipulation between the two interventions, in a result that was downgraded to very low quality due to very serious risk of bias and serious inconsistency between the studies. There was low-quality evidence from six studies that repeated pronation may be more effective than repeat supination-flexion for the second attempt. The remaining outcomes were either not reported (adverse effects, recurrence) or unsuitable for pooling (ultimate failure). Ultimate failure, reported for the overall population, ranged from no ultimate failures in two studies to 4% in one study. One trial compared supination-extension versus supination-flexion and reported very low-quality evidence, downgraded for very serious risk of bias and serious imprecision, for no clear difference in failure at first attempt between the two methods.


Areas of bias identified by the authors included: detection bias, with all four trials at high risk due to lack of assessor blinding; selection bias due to imbalances in key baseline characteristics (age, time from injury, primary or recurrent injury); and performance bias, due to preexisting treatment preferences of clinicians in the studies.



The authors reported that the pronation method was more successful than the supination-flexion method for the first and subsequent repeat attempts at manipulation. However, overall the quality of evidence in this review for individual outcomes was either low or very low, meaning that the results must be viewed with caution.


Implications for Practice

Although many textbooks recommend the use of supination for treatment of pulled elbow in young children, this was not supported by the results of this systematic review where the authors reported that the pronation method was more successful than the supination method, although the level of evidence is low. This reinforces the need for clinicians to remain up-to-date with the latest research to ensure they are providing best practice to their patients.




Krul M., van der Wouden J. C., Kruithof E. J., van Suijlekom-Smit L. W. A., Koes B. W. (2017). Manipulative interventions for reducing pulled elbow in young children (Review).Cochrane Database of Systematic Reviews, (7), CD007759. doi:10.1002/146 51858.CD007759.pub4 [Context Link]